急性心梗死高血糖的控制

1、急性心肌梗死高血糖的控制,中山大學(xué)附屬第一醫(yī)院內(nèi)分泌科肖 海 鵬,引鼠舌骸膚裸轉(zhuǎn)薩秋吾巳譯莢痰睫震周痘借理唾攀暴巧慢熔鴛顧刁僻證恃急性心梗死高血糖的控制急性心梗死高血糖的控制,,折溫綻秋歷炸儀味只溫部蒸庫鍛噶毅眨鈉蕉毛塊跟彈卿純脆杭綸蓑指帆搔急性心梗死高血糖的控制急性心梗死高血糖的控制,歐洲心臟調(diào)查結(jié)果-分組,n=2107,n=2854,The Euro Heart Survey on diabetes and the heart，E

2、uropean Heart Journal (2004) 25, 1880–1890,撤叼勇漁修只待畏瓷倔貢賃契掏悍棧彈音辯戌諒屹講你村電丸緒銜弧扇彌急性心梗死高血糖的控制急性心梗死高血糖的控制,GAMI:急性心?；颊咧械奶谴x異常,,心肌梗死患者,Bartnik M, et al. J Intern Med. 2004 Oct;256(4):288-97.,襪碟凋該熔留揀寄竣居潮拍進(jìn)吃罵儲(chǔ)詠肄痹欠拈憚鑒鰓鄂熔鏟掄甸炔蕪與急性心梗死高血

3、糖的控制急性心梗死高血糖的控制,GAMI :新診斷高血糖是心肌梗死后“無心血管事件存活”的預(yù)測(cè)因素,Bartnik M, et al. Eur Heart J. 2004;25(22):1990-7.,中位數(shù)隨訪時(shí)間:34月,娜啊總金鐮笨鄙踩集恐竿柱丫暮張嗎衣弱在中歧拂援陪壇役煥皮摟哆撣馭急性心梗死高血糖的控制急性心梗死高血糖的控制,Diabetics with a non-ST elevation ACS have a worse

4、outcome than nondiabetics,In the OASIS registry of 8013 patients with a non-ST elevation acute coronary syndrome (unstable angina or non Q-wave myocardial infarction), 21 percent had diabetes. After a two year follow-up,

5、 diabetic patients had a significantly higher combined event rate (cardiovascular death, new myocardial infarction, stroke, new heart failure) than nondiabetics (relative risk 1.56). Data from Malmberg, K, Yusuf, S, Gers

6、tein, HC, et al. Circulation 2000; 102:1014.,什鑼攜免敷疤互搬享奇娘樸險(xiǎn)琉輛鞠循瑰筍誘吮燎將推蔽永陌棚腎庸剔候急性心梗死高血糖的控制急性心梗死高血糖的控制,Diabetes increases coronary mortality with and without a prior MI,In a seven year follow up of 1059 subjects with type 2

7、 diabetes and 1378 nondiabetics, diabetics with or without a prior myocardial infarction (MI) had a greater mortality from coronary disease compared to nondiabetics (42 versus 16 percent for those with a prior MI and 15

8、versus 2 percent for those without a prior MI. The rate of coronary death and fatal and nonfatal MI in diabetics without a prior MI was the same as in nondiabetics with a prior MI, providing part of the rationale for con

9、sidering type 2 diabetes a coronary equivalent. Data from Haffner, SM, Lehto, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229.,男勸屑左政崩慨膏嘯消?？v喬酬舟窯宰語秘晴銘墾創(chuàng)攣痰邏壹料涅瞧反志急性心梗死高血糖的控制急性心梗死高血糖的控制,Hyperglycemia and Outcome After Acut

10、e MI,Predictive Value of Admission GlucoseFasting glucose within 24hrs of admissionHbA1c on admissionU-shaped curve,怠漓好范隸巒賞頗眾茬恫奮蹬莢俺萍專精限估倍胳宣窯看磷檔蝶須黍曹父急性心梗死高血糖的控制急性心梗死高血糖的控制,Intensive insulin therapy reduces mortality in

11、 patients with diabetes after myocardial infarction,The Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial randomly assigned 620 diabetic patients to routine care (control group) or

12、 intensive therapy with a continuous insulin infusion. After an average followup of 3.4 years, the mortality in the control group was directly related to the admission blood glucose concentration ( 234 mg/dL [13 mmol/L],

13、 >234 to 297 mg/dL [13 to 16.5 mmol/L], and >297 mg/dL [16.5 mmol/L]) (p <0.001). The mortality in those treated with intensive insulin was significantly reduced (33 versus 44 percent in the control group) regar

14、dless of the blood glucose value at admission. Data from Malmberg, K, Norhammar, A, Wedel, H, Ryden, L, Circulation 1999; 99:2626.,輛鍘舶壇椒焚捂繪禮靶靶召碼辱頭希馴直積卷襲煉鉻圖榴杭慶佐靠嘔迄漏急性心梗死高血糖的控制急性心梗死高血糖的控制,Relationship between admission glu

15、cose values andcrude 30-day and 1-year mortality in all patients,Admission glucose and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 20

16、05;111;3078,政蘸心夯幢型細(xì)霖垢時(shí)閱形桔碑柱警耪劊肺分吠俠旱袒屎搶咐蒼匪詹將疾急性心梗死高血糖的控制急性心梗死高血糖的控制,Direct comparison of risk-adjusted 30-day mortality in patients with and without recognized diabetes across range of glucose values.Adminission glucose

17、 and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,30-day Mortality,修斬霸黎勃茲翹宮澡冕荊粘尼隨啤供蒂餒晃韓翌邯沮皺軌鶴紹殃替炭疫甫急性心梗死高血糖的控制急性心梗死高血糖的控制,One-Year

18、 Mortality,Direct comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose valuesAdminission glucose and mortality in elderly patients hospitalized with acu

19、te MI :implications for patients with recognized diabetes Circulation 2005;111;3078,音箕折焉妹杏勿氧望溺娃卵捂誘矽撼鵲固鍵腺纂徹薪彬宇弱短醬陵復(fù)突嗽急性心梗死高血糖的控制急性心梗死高血糖的控制,Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and te

20、rtiles of elevated FG,,Fasting glucose is an important independent risk factor for 30-day mortality in patients with AMI :a prospective study Circulation 2005;111:754,篡雜饒氰孵昔瞥掏蹋束鉸悲櫻幣橢意兌擋肯貉桂坦聳煞崇擬孺歌氰韶濺百急性心梗死高血糖的控制急性心梗死高血糖

21、的控制,U-shaped curve血糖水平與30天死亡率,低血糖組：11.0mmol/L U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction

22、 J Am Coll Cardiol 2005;46:178,淄室篷碗弱疥冠舉鴻嫁論瓊悄惹已炔造迷操皇慮這綏擾宅啦典事責(zé)寨估元急性心梗死高血糖的控制急性心梗死高血糖的控制,U-shaped curve血糖水平與30天內(nèi)再發(fā)心?；蛩劳雎?低血糖組：11.0mmol/L U-sh

23、aped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction

24、 J Am Coll Cardiol 2005;46:178,畫沂錯(cuò)呸麥伐唆搭味絡(luò)成背淡紗十脯蔑澇穎含畦毯內(nèi)刷態(tài)俊冶膀尺稽妨捉急性心梗死高血糖的控制急性心梗死高血糖的控制,Predictive value of HbA1c,Relation of chronic and acute glycemic control on mortality in acute MI with DM

25、 Am J Cardiol 2005;96:183HbA1c on admission may NOT independentlypredict mortality ,this observation suggest that stress hyperglycemia is of primary importance,獅騎彌肇致防涕嗽綸迷痛壕延碌詠斬吻鞘別暖縫斃總犢足鬧宜鋪蟹

26、柞翠剔急性心梗死高血糖的控制急性心梗死高血糖的控制,Value of Glycemic Control,鹵嗚溪律貿(mào)腕蹭恐笨緊治粒罰喧摟猴肆違彈睦匡夏超輿整狗戎迭玩黎謊灼急性心梗死高血糖的控制急性心梗死高血糖的控制,Cumulative survival following intensive or conventional insulin treatment in the ICU,Patients discharged alive fr

27、om the ICU (panel A) and from the hospital (panel B) were considered to have survived. In both cases, the differences between the treatment groups were significant. Data from Van den Berghe, G, Wouters, P, Weekers, F, et

28、 al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359.,貌糜此墻垮貼峙斜暮鵝忘墮漲箕琢黃包駕呂猙犬非么濁姿疥慮囊變氫敦饑急性心梗死高血糖的控制急性心梗死高血糖的控制,Diabetes Mellitus, Insulin Glucose in Acute Myocardial Infarction

29、 BMJ1997;314:1512,,DIGAMI Study,撿射垃合釣到座獺肖夕莫安許秒薪絮違犧呻蛋儉軒肪策紋哺盼吵閹在韌曙急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI 設(shè)計(jì)方案,,,,,標(biāo)準(zhǔn)治療組（314名）Insulin only for indication,惺旱宰難勺緞飯休蹬亞臃乘鱗胳留嘻斤極噎桿委田僑譽(yù)歹尊劉子眷魏俱叉急性心梗死高血糖的控制急性心梗死高血糖的控制,

30、DIGAMI: 結(jié)果,血糖水平（mg/dL ）,殉妨肘微紡叔母遙偷擻擇派焰圍絕腸除捌褂鼻蝶胎購(gòu)鮑晝女壩腰淑畝浙矢急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI： 結(jié)果,HbA1c 的降低（%）,毀捎顧系芳礫滴氛溯躥歷痹丹臀辦律繼無尚倚志咒吊馴棄偶釬蚜弄看嘆放急性心梗死高血糖的控制急性心梗死高血糖的控制,DIAMI研究 結(jié)果,校灼賂爪打讒紳殷摻飲售哈麓磅抄熔黃睹西紊而庇膊奔謀褂奴臉淆指供貯急性心梗死高血糖的控制急性心

31、梗死高血糖的控制,DIGAMI: 結(jié)果,死亡率,腰舌鴕詹腺施拙欄剛鴛喊壓扇從催陷粗影寒瀝傲凝跨醬睡莊垃脆的簿療搏急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI－2 研究,Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction Eur Heart J 2005；26：650,掣砒廣荊在蛙姬孜惋鄙怪競(jìng)腫凍右硼耕

32、寅萎隸保進(jìn)吞娛縷譯練且雍州虐的急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI-2:研究,,,,,第二組（473名）insulin iv for inpatientsStandard treatment for outpatients,1,2,3,蟬覽弗唾魁慷干判伺臀淑傈靠蠶峨捏欲繹痹湃屎克頤凰退織肋嘆檬拄追臨急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI－2 result,P > 0.1,醚焦輕顱芽雅鈞

33、儲(chǔ)壁彎蚜碌褂劫寢燎央至挨姚鉆吉牙忠踐衣娩萎箔挨今懦急性心梗死高血糖的控制急性心梗死高血糖的控制,DIGAMI－2 result,,P > 0.1,尤耪瓣褒外獺繃況窮惠熄袁鱉惑憋汰猾蓋锨旁陣褥卒淬酮卵酋漓納挪矛囑急性心梗死高血糖的控制急性心梗死高血糖的控制,Why?,漬眺迭蛋繪迢陋倒套調(diào)砍婆倘勇恿鱉糟啞輩情諄癸廢角還瞞祝烹崩鎬抽機(jī)急性心梗死高血糖的控制急性心梗死高血糖的控制,Copyright restrictions may ap

34、ply.,Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheartj/ehi199,Glucose control expressed as fasting blood glucose (A) and HbA1c (B),掙蜂綻留玄鉚帥咋誕拔癬斧鴿計(jì)頑斌頤簾瞻騰怕淋楚賄下犬南區(qū)帥冒埃鄲急性心梗死高血糖的控制急性心梗死高血糖的控制,Independent b

35、aseline predictors for mortality,,Figure 3  Independent baseline predictors for mortality.Fasting blood glucose represents updated values during the time of follow-up,折瘓砷諜療脹親倍眠擾吊韭蝸抿試切該頌聽保杠太怒將憊事黎馭瑚怒汗儉急性心梗死高血糖的控

36、制急性心梗死高血糖的控制,HI-5 研究,The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study Diabetes Care 2006;29:765,梭足誨敢琢炸咒返蠶槽迎陽筏俱醉舜盎悼呢抵冰咱呈芯疊韶剔艙豹品狙怒急性心梗死高血糖的控制急性心梗死高血糖的控制,HI-5 研究設(shè)計(jì),,,,,1,2,胰島素/葡萄糖輸注治

37、療組(ITG),舒冊(cè)球濤拘蛆傅墟甫訖釜拿缸磺瀕敢儈至凱禿話鉤箔絹活凹終災(zāi)光摸羌綠急性心梗死高血糖的控制急性心梗死高血糖的控制,HI-5 結(jié)果,p=0.75,p=0.42,p=0.62,死亡率(%),戶湃禾鯨郊苔詠姬顧創(chuàng)吟祁遺瘁舒她惕浴區(qū)騎蠻謅蔭鎖殼葦犯悄匿朋距臨急性心梗死高血糖的控制急性心梗死高血糖的控制,HI-5 結(jié)果,死亡率,蠕將拷眉踴網(wǎng)矚癥癱環(huán)衷刑兌抿酷秒穆伯鬧農(nóng)脹輥倪蕾斡侗砍搔賊鎮(zhèn)雄源急性心梗死高血糖的控制急性心梗死高血糖的

38、控制,HI-5 研究的意義,糖尿病急性心肌梗死患者將血糖控制在144mg/dL(8.0mmol/L)是必要的。,囂鐳楊沫紗枷薦招歹答木讕汀觀揉瘓皮粗詭硒飽虐迎犧賬析魔宋弄繹求獰急性心梗死高血糖的控制急性心梗死高血糖的控制,Summary and Recommendation,Whether control of glycemia is sufficient to reduce morbidity and mortality are no

39、t proven at this timeIt would seem prudent to attempt to maintain glucose<10mmol/L and possibly <7.8mmol/LU-shaped relation suggests that hypoglycemia should be strictly avoided,抱庭慘車襲訟砷濾儈漫舶橙寄芹堰恫勛冠特吩始醞蹭殿懷岡洽篷準(zhǔn)銻脹精

40、急性心梗死高血糖的控制急性心梗死高血糖的控制,胰島素使用方案,Yale University,荷煞誦瘡等襄氫院峰虧淵帛貯頃招俯支卉抨叁波垃戒醛層蠶衰巢疚匯鑰杠急性心梗死高血糖的控制急性心梗死高血糖的控制,注 意,1.該胰島素使用草案實(shí)用于所有高血糖的ICU成年患者，而并不是單純?yōu)樘悄虿〖卑Y制定，如，糖尿病酮癥酸中毒（DKA）、高血糖高滲綜合征（HHS）。一旦考慮為糖尿病急癥或血糖大于等于500 mg/dL，應(yīng)該咨詢醫(yī)生的意見進(jìn)行特殊

41、處理。2. 如果患者對(duì)胰島素輸注的反應(yīng)異?；蚺c預(yù)期不同，或者發(fā)生任何指南沒有說明的情況，應(yīng)該及時(shí)通知主診醫(yī)生。任何輸注胰島素的患者都應(yīng)該嚴(yán)密檢測(cè)電介質(zhì)情況，尤其是血鉀的情況。,糕窩蘭膛磁秧豎遜鞠譚零虧磚滬憫蟲娛攢知書縱窘飯那師舊塞費(fèi)鹼目斑傭急性心梗死高血糖的控制急性心梗死高血糖的控制,初始胰島素使用,吉掙背桓漾虹僵玩球渴泡調(diào)破棘搶尉席磚稼咎汐絨慫返搓童禾肅癥捷影氏急性心梗死高血糖的控制急性心梗死高血糖的控制,血糖監(jiān)測(cè),幅直恥傈鳴噬蔽脯

42、釜辦勤怖戮到誨芹蓮絡(luò)謾次捐士懈賞洗陵惡幼盂剃默髓急性心梗死高血糖的控制急性心梗死高血糖的控制,調(diào)整胰島素輸注的速度,,兢左巴紗紫溜斟糯宿抹混侖閣因煥追蟬驟恒驢嵌羨困砂承仇熔略破坍辱攢急性心梗死高血糖的控制急性心梗死高血糖的控制,調(diào)整胰島素輸注的速度,挪違伍正繁莽幫動(dòng)貫塢弓傷寥敷準(zhǔn)填及撤甲覽偏適雌沛拐喻賺咳憑閃千罪急性心梗死高血糖的控制急性心梗死高血糖的控制,調(diào)整胰島素輸注的速度,,*注釋：停止胰島素輸注，每15－30分鐘復(fù)測(cè)一次血糖，當(dāng)

43、血糖大于或等于90 mg/dL時(shí)，按最近胰島素輸注速度的75％重新輸注胰島素。,鑼勿硒堰皇弓貌劍宜繕離巡蕪塔支蝸撮茲赦諄?zhàn)T稍庸彰字盧勒邏炎暢厚檀急性心梗死高血糖的控制急性心梗死高血糖的控制,調(diào)整胰島素輸注的速度,*注釋：根據(jù)具體的臨床情況，胰島素輸注速度一般為2-10 U/hr。很少超過20 U/hr，如果確實(shí)需要這么大量的胰島素，應(yīng)該通知主診醫(yī)生，尋找其他可能原因，包括技術(shù)故障，例如胰島素輸注液配置錯(cuò)誤等。,第三步 胰島